-Case-
You’re on shift when a 22-year-old is rushed into the ED by his worried parents. His left eye is tender and swollen shut, with redness around it. They mention he’d been battling a “minor cold” over the past week, but today his fever spiked, and he started complaining of pain with eye movement. He is febrile to 102.4F and he cannot see out of his left eye unless you pry his swollen eye lids open.
Pain with eye movement is certainly a worrisome symptom. In the absence of any eye trauma/concern for orbital fracture, there is one infectious pathology in specific that we should be worried about in the ED…
-Evaluation-
Orbital cellulitis is an emergency that requires quick recognition and action. The classic presentation includes typically unilateral periorbital swelling, erythema, and warmth. As in our case above, pain with eye movement is a significant red flag for orbital involvement, and in these cases, fever often accompanies it. Proptosis is also a scary sign as it can indicate even deeper orbital involvement, and vision changes (think diplopia, blurred vision) are concerning for optic nerve compression.
Risk factors for orbital cellulitis include recent sinusitis (the most common cause), trauma or surgery involving the orbit, dental infections, immunosuppression, and/or systemic infections.
For diagnosis, imaging plays a crucial role. A CT scan of the orbits with contrast is the preferred modality to confirm this diagnosis and identify complications such as abscesses or intracranial extension. In uncomplicated cases of orbital cellulitis, imaging will likely show evidence of inflammation of the extraocular muscles, fat stranding, and anterior globe displacement.
Now, orbital cellulitis exists on a spectrum of ocular infections; it’s crucial to differentiate between orbital and preseptal cellulitis:
- Preseptal Cellulitis: limited to anterior ocular structures; typically presents with no pain with eye movement, no proptosis, and no vision changes
- Orbital Cellulitis: affects structures posterior to the orbital septum; you can expect pain with eye movement, proptosis, or visual disturbances
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-Management-
Prompt intervention is key when it comes to orbital cellulitis. Here’s the plan:
- Antibiotics: for starters, IV broad-spectrum antibiotic coverage is essential. Start with agents like vancomycin with ceftriaxone, or cefotaxime alone. Add metronidazole if anaerobes are suspected.
- Ophthalmology Consultation: early involvement is critical, especially if there’s vision loss, signs of complications on CT, or lack of improvement with initial antibiotics
- Surgical Intervention: indicated for orbital abscesses, subperiosteal abscesses, or intracranial complications; usually, cases are caught before they progress to this, but again, a CT scan here is key!
-Fast Facts-
- The most common cause of orbital cellulitis is the spread from adjacent sinusitis, particularly the ethmoid sinuses
- Complications like optic nerve damage, cavernous sinus thrombosis, intracranial abscesses, or blindness are worrisome in cases of orbital cellulitis not caught/addressed early
- Pain with eye movement and proptosis should make orbital cellulitis your chief concern until proven otherwise
Orbital cellulitis is no ordinary eye infection; early diagnosis and aggressive treatment can save a patient’s vision and prevent nasty complications. In the ED, quick thinking and action make all the difference!
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Cheers,
Tamir Zitelny, MD